We have a wonderfully committed and talented Afghan staff working at the U.S. Embassy in Kabul. Many of them work at peril to themselves or their families, such that no one knows outside of their immediate family where they work. This lowers the risk of threats, violence or ransom-related kidnappings. American Embassy employees rely daily on the language skills, local knowledge and commitment to improving life in Afghanistan demonstrated by our loyal local staff.
A story of caring for our staff is an uplifting counterpoint to the daily news of terrorist attacks. Let me share it with you. Abdullah (not his real name) is a young married man and new father, 26 years old, who has worked in an Embassy office for over five years. He was seeking advice from an Indian physician about his 15 month-old daughter, but found himself in the wrong place at the wrong time.
On February 26, 2010, terrorists attacked an Indian guest house several miles away from the Embassy. The initial blast from a suicide bomber could be heard and felt inside my concrete apartment building early on a Friday morning. This was followed by a gun battle of Afghan police/army forces and the terrorists. The battle lasted several hours, with all the terrorists killed or captured. A number of Indian physicians visiting Kabul for a conference were killed. Abdullah was shot in the abdomen as a bystander.
Afghan National Army (ANA) soldiers were able to transfer Abdullah to the nearby ANA Hospital where he received heroic initial care. He was losing blood rapidly from internal injuries and had several gaping abdominal wounds. Doctors were able to quickly establish IV lines and begin IV fluids and rapid blood transfusion. Most people would have died from the initial blood loss, but Abdullah – all 150 pounds of him – was strong and determined to survive. After all, he had a beautiful wife of two years and precious toddler waiting for "padar" (papa) to come home.
He was taken immediately to surgery where his wounds were found to be complex – massive injury and perforation of part of the large intestine, multiple small perforations to the small intestine, a rapidly bleeding tear to part of the spleen and more. Despite the fact that Abdullah was not an ANA soldier (doctors did not know he worked at the U.S. Embassy at all) doctors worked for over four hours to remove part of the colon, close perforations of the small bowel, sew the torn spleen and rinse, rinse, rinse the abdominal contents of all the bowel spillage that spelled certain infection. Without the heroic efforts of the Afghan physicians, working in a hospital with rudimentary equipment and short-stocked on meds and supplies, Abdullah would have died within hours. Following surgery, his journey to health would be fraught with dangerous challenges, but he now had the chance to take that perilous journey.
I received a call late that day from the head of his section of the Embassy, concerned about his employee’s progress and dangerous prognosis. Was there anything I could do? Having never been to the ANA Hospital, I was concerned that my involvement would be met with resistance – a meddling U.S. doctor who is not a trauma surgeon, walking in to the top Afghan military hospital in Afghanistan to scrutinize the care given. What could a country family doctor do in a situation like this?
Anxious to help but hesitant to “make waves”, I called in my health unit colleague, an Afghan physician who had once worked at the ANA hospital and had many long-standing friends there. “Dr. Ahmad” was a tremendous help in getting me access to the hospital and introducing me to Abdullah’s care team. I met an American naval surgeon who was serving as a mentor at the ANA hospital. He quickly informed me of the lack of resources for this large hospital, but also of the hard-working commitment of the local Afghan military physicians.
Abdullah was doing poorly when we saw him; he drifted in and out of consciousness, in severe pain when awake. He had a colostomy bag on the right abdomen following removal of much of his colon. He had a high heart rate and rapid breathing. He developed a fever within 12 hours of the surgery. He continued to require additional blood transfusions to replace blood loss prior to surgery.
Abdullah's father implored us to intervene – to have him transferred to our top American military trauma hospital in Bagram (one-hour drive or fifteen minute helicopter ride away). The father felt certain that his son would not survive if he stayed at the ANA hospital, but had full faith that “the American doctors” could bring about a miracle. Doctors agreed that I could help by supplying additional medications. The 300-bed hospital was very poorly supplied and did not have any more morphine for pain control. They lacked the strong antibiotics that could help fight the expected life-threatening infection from bowel spillage internally. They lacked high-tech internal monitoring devices, and the one CT scanner installed a year earlier sat idle, awaiting replacement parts that never arrive.
It was clear to me that without additional intervention, Abdullah would die within days. I was able to share morphine and strong antibiotics from our supply at the Embassy health unit. I contacted the chief of trauma at the American field hospital at Bagram. They are permitted to treat local civilians when they have excess capacity (low incoming wounded Americans) but this would be a challenging case and occupy a bed for longer than desired or typically OK’d. I gauged the feelings of the Afghan physicians who were proud of the work they had done to save him, and knew they lacked resources, but felt he “should be watched” to see if he gets better. By this time I had the interest and support of Ambassador Eikenberry and many top leaders at the Embassy who encouraged all to “do what it takes” to pull Abdullah through.
By the second post-op day, Abdullah was doing worse. He now had a 104-degree F temperature, rapid, faint heartbeat, and more labored breathing. No CT scan was available, but his chest x-ray showed fluid building up in the right lung. It was time to take action. Here is where “medical diplomacy” comes into play, along with experience of arranging rural to urban transfers of very ill patients and keeping the many involved parties informed.
I explained to the Afghan doctors that we have the ability to work in teams, finding the best resources available, and building on the care already given. Additional resources (CT scanner, ICU, monitoring equipment, not to mention highly trained U.S. trauma surgeons and critical care specialists) could be available to help Abdullah. From the surgical team at Bagram, I received permission to transfer the patient, after making a direct request on behalf of the American Ambassador -- but a helicopter was not available and Abdullah would need to be driven by ground ambulance over one of the very dangerous roads in Afghanistan. I prayed for a safe journey, that Abdullah would survive long enough to get to Bagram.
He made it. Upon arrival a CT scan was performed. It revealed previously unknown injury to the diaphragm, blood filling the left side of the chest, and large fluid (blood and pus) cavities developing in the abdominal wall and inner abdomen. He was taken straight to the operating room for an additional four hours of surgery and came back to the ICU on a ventilator, with two chest tubes, abdominal drains, and on multiple modern meds given via calibrated infusion pumps.
Abdullah made it through the next few days, fighting, fighting for life. He recalls none of the first two weeks after being shot.
He required over nine trips back to the operating room and remained at Bagram hospital for six weeks, the first week on the ventilator in an induced coma. He battled infection in the abdomen, a breakdown of his abdominal incision, pneumonia, and other complications. He had a family member (father, brother, or cousin) stay with him – sleeping on the floor – to offer support, encouragement, and prayers. Abdullah’s weight dropped from 150 to 127 pounds. His nutritional state remained complicated since his bowel did not function as it had and his appetite was poor. Yet he needed protein to allow new tissue to heal and skin cells to regenerate to close the gaping abdominal wound that had had to be left open. Intravenous nutrition and later a feeding tube worked to strengthen him. Eventually he was able to receive a skin graft to the abdominal wound, was able to regain eating and could tentatively start to get out of bed and begin some strengthening.
He was receiving great support from the Embassy during this time. Ambassador Eikenberry visited him early at the ANA hospital and received frequent updates from me on his progress. In addition to daily phone calls and frequent email updates to Embassy leaders, I was able to travel to Bagram to visit him and confer in person with the physicians that had pulled him through. They called Abdullah “one of our miracle cases”. During my visit, Abdullah remained weak, tired and discouraged that he would never get out of the hospital. I helped him focus on his future, his family, his daughter’s need of a strong father. His strong spirituality gradually helped him feel a sense of purpose – that he must get better to do important, positive work in his life. His medical and emotional condition gradually improved and he was readied from transfer home on April 12, after more than six weeks of multiple surgeries and touch-and-go episodes.
I was able to provide his ongoing care in the Embassy health unit with every-other-day wound care, nutritional support, pain management, teaching ostomy care, and offering emotional support. Slowly he gained strength, could manage to walk without support and transfer out of bed alone. He began to smile often. How we cheered when he finally showed a three-pound weight gain! Abdullah was a man reborn, so thankful for his life, his family, his hopeful future. He began bringing in family pictures and talking of returning to work in the weeks to come.
It took another month of frequent visits for his skin grafts to fully heal, colostomy to function just right, diet to get back to normal and to become independent in daily cares. At the end of May, Abdullah was finally able to return to work at the Embassy for partial days and is now working full time. But his story is not yet ended.
The army hospital has agreed to see Abdullah once again in October, 2010, when he will be strong enough to undergo additional surgery. He will be able to have his large intestine “reconnected” and will get a graft to the front of the abdomen that will fix the wound hernia that developed as an expected result of his earlier wound breakdown.
For the heroic work done by all the doctors involved, Ambassador Eikenberry wrote special commendations for the Afghan physicians and nurses from the ANA hospital, without whose efforts Abdullah would have died. It was a special day when I represented the Ambassador at an award ceremony at the ANA hospital and could speak of successful collaboration on this very challenging case. What could have been an uncomfortable loss of face for the Afghan medical staff as we “pulled their patient out of their hospital” turned out to be a celebration of cooperative resource-sharing between two hospital teams that had rarely worked together before. The Afghan team was extremely proud of their work and the recognition from the Ambassador and the very appreciative Embassy community. Abdullah attended the ceremony with me, offering a tearful and sincere thank you to the military doctors for giving a son back to his parents, a husband back to his wife, and a father back to his small daughter. All eyes in the large room were moist.
I was also able to travel back to Bagram to present Ambassadorial awards to the American care team. During that visit I shared the story of Abdullah’s journey, family, and valuable work at the Embassy. So busy are the miracle-working American military physicians that they rarely get to actually know the stories behind the many patients whose lives are given back to them. They heard how their intervention cemented the loyalty of hundreds of Afghan Embassy employees who now truly believe our guiding principle – "One Team, One Mission".
Taking on just a small role in coordinating the care of Abdullah has been the most rewarding experience of my tour in Afghanistan. I will never forget Abdullah and his young family, facing the future with thanks to the United States and full of hope for Afghanistan.
Saturday, July 10, 2010
Friday, February 26, 2010
Drs. Dave and Pat - February 26, 2010
Both Drs. David Gahn (top) and Pat O'Connor (below)have been coming to Kabul from the U.S. several times per year for 4-6 weeks at a time, working to build a safer system for women with obstetric complications. Their work has been responsible for a lower maternal mortality rate, which has been among the highest in the world. Pat is from Arizona and David lives in Oklahoma. They are two of the thousands of Americans working hard to make a difference in Afghanistan.
Notes from a Friend - February 26, 2010
I am including a well-written email to friends and family from Dr. Pat O'Connor. He is a pediatrician who has served in the Indian Health Service for a number of years. He is working in Kabul as part of a team that is teaching and developing improved levels of obstetric and newborn health care at one of Kabul's largest maternity hospitals. Resident physicians, their supervisors and a host of midwives performed 72 deliveries there one day this past week. Many of the women have little or no prenatal care available, and only come to the hospital if suffering complications.
Pat and Dr. David Gahn (OB-Gyn and director of this program) have been sharing my apartment with me this past month as housing gets tighter in the ever-expanding Embassy mission in Afghanistan. Both have become great colleagues and friends.
Dear Friends,
I apologize for my lack of writing so far this trip. It's been a trip that has been far more meeting-heavy, and less clinical work, than usual. Unexpectedly, that has made it more busy for me, and I just haven't gotten around to writing ya'll. The "meeting work day" can run the gamut of times, but often involves writing reports on each of the meetings that I attend. The clinical work day is usually 8:30 am to 3:30 pm, as the on call staff at the hospital take over about 3 pm, because the daytime docs (attendings as well as residents) head off to their private clinics. And the "clinical work day" doesn't require near so many written reports...hence my longer working days....
The private clinics are the places that allow Afghan doctors the ability to provide for their families. The salary for a doctor working at a government hospital like Rabia Balkhi used to be $30 per month (when we started in 2003), though now this has been increased to about $250 per month. By comparison, an NGO (non-governmental organization; e.g. CARE International) may offer $1000/month to an Afghan to serve as an interpreter. Indeed, many of the doctors in this country, by virtue of their needing to learn English as the language of medicine, are far better off interpreting, rather than practicing. And it is surprisingly expensive to live here (rents for a family are commonly $400 to $800 per month). A figure that has also been inflated by the presence of foreigners who need a place to stay. This demand really drives up the rent, since the housing is quite limited. There are thousands of civilian foreigners here, many doing great work, but the economic impact for the locals can be surprisingly negative.
And this subject of the economy brings me to my first story. Recently a mother and grandmother brought a very little baby to the nursery at RBH to see my pediatric colleague, Dr. Anis Azizi. He is the "true" pediatrician that I work with, who I've bragged about before. He is now working for our project to follow-up every baby and mother who is delivered by C-section at Rabia Balkhi. This amounts to about 1200 C-sections per year. He contacts each family by mobile phone, and gets information on the mother and baby for up to two years after the c-section. One unexpected bonus of this follow-up is that the people are incredibly appreciative (and surprised) that anyone would care to see how they were doing. And Dr. Anis has been able to give a lot of great pediatric telephone advice to families, when they have a concern about their baby or the mother. This family felt that the baby seemed fussy a lot of the time. So he suggested they bring the baby to see him in the nursery. Turns out that the baby was born very small--1500 grams, or 3 lbs. 5 oz. We have learned from this project that almost every baby born at 1500 gr. and below will die: this is just reality in a resource poor country. Babies under that weight require the kind of high tech care that is routinely delivered in American neonatal intensive care units, but there are none of those in Afghanistan.
Anyway, somehow this baby survived, and is now just over 2 months old. But his weight upon arrival in the nursery was 1.71 kg or a whopping 3 lbs 12 oz. No wonder the infant was fussy--he was starving! And he looked it: all his bones were showing, and he had this "worried" and hyper-alert expression that is typical of starving babies. The mother simply didn't have enough breast milk, possibly partly because the baby was so small and weak, that it just couldn't nurse very well. The baby otherwise looked healthy, and probably just needed to be fed to be able to survive. The family reported that they couldn't afford formula. Dr. Anis found out that the father worked as a cook, and was supporting 5 people besides the baby. He was paid $150/month. The cost of formula (a seldom used thing among the general population in Afghanistan) was about $50/month. There did not seem to be any source of "charity" milk, and so I gave the family $40, which will feed the baby for almost a month. If the mother continues to try to breast feed, and supplements with the formula, this may be enough to allow the child to grow larger and stronger that he may be able to breast feed well on his own and grow into a normal child. Dr. Anis will have the baby return to our nursery in one week so that we can see if he is taking to the formula, and if he has gained weight.
Now to the other extreme: three days ago, I was called by the Director of Rabia Balkhi Hospital, Dr. Najia Tareq. She said that she was speaking with her good friend (and former med school classmate), the First Lady of Afghanistan, about the First Baby. Dr. Najia told Mrs/Dr Karzai that her son was "too fatty," and that she barely recognized him. The First Lady asked if Dr. Najia knew of a good pediatrician, and she suggested the American pediatrician (me!). I was asked to come to the Presidential Palace to examine the child, to see if there was a medical problem with the child. So, after my day of work at Rabia Balkhi, I met Dr. Najia at the entrance to the Presidential Palace and we were escorted on to the grounds. It is a huge complex with a 16 foot stone wall around it, and includes several important Ministry Buildings (like the Ministry of Defense), as well as the living quarters of the First Family. The actual palace is occupied by the relatives of the former king, Zahir Shah, who returned to Afghanistan in 2002 and died here in 2007. He had ruled for 40 years, until 1973 when he went on a trip to Italy. While he was out of the country, his cousin, Daoud, overthrew the monarchy, and started a communist regime, with the assistance of the Soviet Union. This was the beginning of the wars, civil and otherwise, that ravaged the country for the next 30 years.
The relatives of Zahir Shah are allowed to live in the real Palace, out of national "respect" for the family. The Karzai's live in one of the nearby houses, that were originally designed for the relatives of the king, and that is where Dr. Najia and I met the First Lady and Mirwais, her son. The house was very nice, of course, though I only made it to the large sitting room. Mirwais had just turned three, and was playing around in the room with his toy attack helicopter. I thought that was a little sad at first, thinking that he was a child of war, but then quickly thought what every 3 year old boy in the USA wanted to play with--probably an attack helicopter. He was very verbal, and playful, and active, and seemed like a pretty normal 3 year old. I talked to the First Lady about his developmental history, and medical history, and about his diet. She wanted to make sure that he didn't have some kind of "glandular" problem as the cause for his weight. We then weighed him (24.0 kg) and took his height (99cm), and calculated his BMI (24.5). I then gave him a good exam, and delivered my diagnosis: the first "baby" of Afghanistan is FAT!! Everything else on his exam was just fine. And he didn't come close to the heftiest of the American fatties that I've seen. So, we just talked about the usual things: limit television/video time (he doesn't watch TV or play video games), keep him active, and eat a lot more vegetables and fruits. Turns out that his three main food groups were rice, meat and whole milk; a certain recipe for largeness.
I was very nervous going in for the examination, but during my visit, I just felt like I was talking to any other concerned mother about her child. Mrs. Karzai was very pleasant to talk with and asked good questions and was very receptive to advice. I got to play tickle games and peekaboo with the First Baby, while she and her friend, Dr. Najia, took some time to catch up. The First Lady thanked me for coming over to the Palace, and seemed quite relieved that I didn't believe that there was any medical problem with her only son.
As I near my retirement from the US Public Health Service, I am now considering limiting my practice to those children of Royal, or at least, Presidential, birth. Please feel free to forward any referrals who meet that criteria.
I hope all is well back home for you all. I leave for Tucson in one week, on 3 March, and hear that the desert Southwest should have a GORGEOUS Spring because of all the recent rain. I can't wait.
Salaam,
Pat
Pat and Dr. David Gahn (OB-Gyn and director of this program) have been sharing my apartment with me this past month as housing gets tighter in the ever-expanding Embassy mission in Afghanistan. Both have become great colleagues and friends.
Dear Friends,
I apologize for my lack of writing so far this trip. It's been a trip that has been far more meeting-heavy, and less clinical work, than usual. Unexpectedly, that has made it more busy for me, and I just haven't gotten around to writing ya'll. The "meeting work day" can run the gamut of times, but often involves writing reports on each of the meetings that I attend. The clinical work day is usually 8:30 am to 3:30 pm, as the on call staff at the hospital take over about 3 pm, because the daytime docs (attendings as well as residents) head off to their private clinics. And the "clinical work day" doesn't require near so many written reports...hence my longer working days....
The private clinics are the places that allow Afghan doctors the ability to provide for their families. The salary for a doctor working at a government hospital like Rabia Balkhi used to be $30 per month (when we started in 2003), though now this has been increased to about $250 per month. By comparison, an NGO (non-governmental organization; e.g. CARE International) may offer $1000/month to an Afghan to serve as an interpreter. Indeed, many of the doctors in this country, by virtue of their needing to learn English as the language of medicine, are far better off interpreting, rather than practicing. And it is surprisingly expensive to live here (rents for a family are commonly $400 to $800 per month). A figure that has also been inflated by the presence of foreigners who need a place to stay. This demand really drives up the rent, since the housing is quite limited. There are thousands of civilian foreigners here, many doing great work, but the economic impact for the locals can be surprisingly negative.
And this subject of the economy brings me to my first story. Recently a mother and grandmother brought a very little baby to the nursery at RBH to see my pediatric colleague, Dr. Anis Azizi. He is the "true" pediatrician that I work with, who I've bragged about before. He is now working for our project to follow-up every baby and mother who is delivered by C-section at Rabia Balkhi. This amounts to about 1200 C-sections per year. He contacts each family by mobile phone, and gets information on the mother and baby for up to two years after the c-section. One unexpected bonus of this follow-up is that the people are incredibly appreciative (and surprised) that anyone would care to see how they were doing. And Dr. Anis has been able to give a lot of great pediatric telephone advice to families, when they have a concern about their baby or the mother. This family felt that the baby seemed fussy a lot of the time. So he suggested they bring the baby to see him in the nursery. Turns out that the baby was born very small--1500 grams, or 3 lbs. 5 oz. We have learned from this project that almost every baby born at 1500 gr. and below will die: this is just reality in a resource poor country. Babies under that weight require the kind of high tech care that is routinely delivered in American neonatal intensive care units, but there are none of those in Afghanistan.
Anyway, somehow this baby survived, and is now just over 2 months old. But his weight upon arrival in the nursery was 1.71 kg or a whopping 3 lbs 12 oz. No wonder the infant was fussy--he was starving! And he looked it: all his bones were showing, and he had this "worried" and hyper-alert expression that is typical of starving babies. The mother simply didn't have enough breast milk, possibly partly because the baby was so small and weak, that it just couldn't nurse very well. The baby otherwise looked healthy, and probably just needed to be fed to be able to survive. The family reported that they couldn't afford formula. Dr. Anis found out that the father worked as a cook, and was supporting 5 people besides the baby. He was paid $150/month. The cost of formula (a seldom used thing among the general population in Afghanistan) was about $50/month. There did not seem to be any source of "charity" milk, and so I gave the family $40, which will feed the baby for almost a month. If the mother continues to try to breast feed, and supplements with the formula, this may be enough to allow the child to grow larger and stronger that he may be able to breast feed well on his own and grow into a normal child. Dr. Anis will have the baby return to our nursery in one week so that we can see if he is taking to the formula, and if he has gained weight.
Now to the other extreme: three days ago, I was called by the Director of Rabia Balkhi Hospital, Dr. Najia Tareq. She said that she was speaking with her good friend (and former med school classmate), the First Lady of Afghanistan, about the First Baby. Dr. Najia told Mrs/Dr Karzai that her son was "too fatty," and that she barely recognized him. The First Lady asked if Dr. Najia knew of a good pediatrician, and she suggested the American pediatrician (me!). I was asked to come to the Presidential Palace to examine the child, to see if there was a medical problem with the child. So, after my day of work at Rabia Balkhi, I met Dr. Najia at the entrance to the Presidential Palace and we were escorted on to the grounds. It is a huge complex with a 16 foot stone wall around it, and includes several important Ministry Buildings (like the Ministry of Defense), as well as the living quarters of the First Family. The actual palace is occupied by the relatives of the former king, Zahir Shah, who returned to Afghanistan in 2002 and died here in 2007. He had ruled for 40 years, until 1973 when he went on a trip to Italy. While he was out of the country, his cousin, Daoud, overthrew the monarchy, and started a communist regime, with the assistance of the Soviet Union. This was the beginning of the wars, civil and otherwise, that ravaged the country for the next 30 years.
The relatives of Zahir Shah are allowed to live in the real Palace, out of national "respect" for the family. The Karzai's live in one of the nearby houses, that were originally designed for the relatives of the king, and that is where Dr. Najia and I met the First Lady and Mirwais, her son. The house was very nice, of course, though I only made it to the large sitting room. Mirwais had just turned three, and was playing around in the room with his toy attack helicopter. I thought that was a little sad at first, thinking that he was a child of war, but then quickly thought what every 3 year old boy in the USA wanted to play with--probably an attack helicopter. He was very verbal, and playful, and active, and seemed like a pretty normal 3 year old. I talked to the First Lady about his developmental history, and medical history, and about his diet. She wanted to make sure that he didn't have some kind of "glandular" problem as the cause for his weight. We then weighed him (24.0 kg) and took his height (99cm), and calculated his BMI (24.5). I then gave him a good exam, and delivered my diagnosis: the first "baby" of Afghanistan is FAT!! Everything else on his exam was just fine. And he didn't come close to the heftiest of the American fatties that I've seen. So, we just talked about the usual things: limit television/video time (he doesn't watch TV or play video games), keep him active, and eat a lot more vegetables and fruits. Turns out that his three main food groups were rice, meat and whole milk; a certain recipe for largeness.
I was very nervous going in for the examination, but during my visit, I just felt like I was talking to any other concerned mother about her child. Mrs. Karzai was very pleasant to talk with and asked good questions and was very receptive to advice. I got to play tickle games and peekaboo with the First Baby, while she and her friend, Dr. Najia, took some time to catch up. The First Lady thanked me for coming over to the Palace, and seemed quite relieved that I didn't believe that there was any medical problem with her only son.
As I near my retirement from the US Public Health Service, I am now considering limiting my practice to those children of Royal, or at least, Presidential, birth. Please feel free to forward any referrals who meet that criteria.
I hope all is well back home for you all. I leave for Tucson in one week, on 3 March, and hear that the desert Southwest should have a GORGEOUS Spring because of all the recent rain. I can't wait.
Salaam,
Pat
Sunday, January 31, 2010
January 31, 2010 - Update from Kabul
Life has been busy, hence few blog entries. It was heartwarming to be home in Minnesota over the Christmas holidays, seeing and greeting many friends, colleagues and spending time with family. I was somewhat humbled by how many of you told me you followed this blog and looked forward to posts. Sorry the entries are somewhat few and far between. Rest assured I am safe, challenged and fascinated by the work I am doing.
Interesting challenges continue every few weeks in Kabul. We have had the usual many cases of “Kabul crud” which is a respiratory virus complicated by the dirty, smoke-filled air of Kabul. It causes a more prolonged cough along with an increase in sinus infections, asthma flare-ups and even occasional cases of pneumonia. More people arrive in Kabul daily, but not all arrive healthy. More of the one-year contract workers for the Department of State, USAID and the Department of Agriculture are recently retired folks in their 60s to early 70s. They have much-needed skills, but also have the ills many in that age group share – obesity, arthritis, high blood pressure, current or former heart disease, high blood pressure, and even some with diabetes. We work with them the best we can to cover their health care needs. This is not so difficult in Kabul where I have good assistants, a small lab in the health unit, a reference lab in the city, and basic x-rays available at an army base located in Kabul. Managing chronic health conditions in the Provincial Reconstruction Teams (PRTs) is much more difficult because there is no ready access to a lab, x-ray, or hospital. Some PRTs are staffed with physicians in a small MASH-like stabilization tent or Quonset hut. If an emergency arises, people from the PRTs must be helicopter-evacuated to one of 6 regional field hospitals run by various NATO countries. If there is a concurrent emergency need by soldiers for the same helicopters, the military personnel come first. Specific arrangements (Memoranda of Agreement, or MOA) must be executed with each hospital host country to allow USG civilian employees access to medical services.
When someone is seriously ill, I need to use the resources of the French-run military stabilization/evacuation hospital in Kabul. That was especially interesting when I had a man in his 50’s with chest pain and poor heart rhythms that needed to be stabilized and then evacuated to Germany for an angiogram. I was at the hospital, working along with French, Portuguese and German physicians to get him stabilized and ready for transport. It was fascinating to serve together with these talented physicians from other countries. It was even better that we all agreed on exactly what medications, tests, and treatments were needed. Fortunately, that patient did very well as he was eventually treated with a balloon angioplasty and stent to his main heart artery.
We must always be prepared for a medical crisis from fighting in the city. Although Kabul has been relatively safe and stable for many months, there have been several attacks and car bombings by Taliban fighters in recent weeks. I was recently speaking at a medical orientation for new arrivals, when nearby bombs exploded, one after another for an hour or so. That attack, put down successfully by the Afghan army and police, occurred about 1 mile from the embassy. It has caused us to redouble all the security arrangements. We do not travel outside of the embassy compound unless necessary for business or emergencies. So far, no embassy civilians have been hurt or killed in Kabul. But the coming months will remain dangerous. We continue with training and mass casualty drills to be ready for possible injuries in the future.
I recently had the chance to venture outside of Kabul to visit two of the four Regional Command Platforms that serve as headquarters for the USG civilians from many agencies that serve throughout the country in the local provinces. In mid-2008 there were fewer than 50 civilians working in the outlying areas; now there are over 300, with another 300 planned over the coming year. They serve at 64 different outposts. I visited Mazar-i-Sharif in the north and Kandahar in the south. In each command location a small group of civilians live and work among the thousands of army troops. They coordinate the activities of all the people working in the small PRTs and District Support Teams (DSTs). Living accommodations are austere, with barrack accommodations, shared bath facilities, mess hall eating and little opportunity for private space or private time. At the most remote posts, the DSTs, 1-3 American civilians are imbedded with 150-200 soldiers. They live in tents, use latrines, and clean up daily with what amounts to an oversized “Baby Wipe”. Nonetheless, the people I met were hard-working, optimistic and committed to making life better for the Afghan people and helping them develop local and regional government structures that serve the needs of the local population. That is their primary mission, as the military forces oust the Taliban, provide basic security for local villages and cities, and assist in fostering a sense of trust in the local people.
My travel to a small Canadian-run PRT was exciting. I hitched a ride with Canadian troops on a night-time military convoy in armored troop carriers equipped with night-vision cameras. We frequently had to stop while soldiers patrolled the ditches and nearby mud huts for any threats or signs of mines or IEDs along the road. Of course we all wore armored vests and helmets, huddled on our bench seats in a cramped posture for the 1 ½ hour journey. The night I traveled was lucky – the only moving things noted on the scanner were stray dogs and several camels in the yards of their owners! Not all convoys go so well. I now have a first-hand appreciation of the cautious apprehension that is a part of every convoy in a war zone.
The most heart-warming event in my stay in Afghanistan so far occurred while visiting the PRT on the northern outskirts of Kandahar city, where fighting has been fierce in the past two years. A local family brought their 2 year-old daughter to the tiny military health unit after she was scalded by spilled boiling tea down her entire torso. She had extensive burns, not adequately treated by a local physician. I was able to teach a young Canadian physician (just completed her training in the past year) to debride the burn wounds carefully, followed by special antibiotic application and dressings. It will likely take treatments 2-3 times a week for another month, but I think the beautiful girl, named Assima, will eventually heal the wounds. Her father was very appreciative. It is the type of diplomacy that works wonders in building trusting relationships.
Life is full of contrasts. 6 days after returning from the Kandahar province, I packed my bag to head off to Bangkok, Thailand for the annual medical conference sponsored by the Office of Medical Services….
Interesting challenges continue every few weeks in Kabul. We have had the usual many cases of “Kabul crud” which is a respiratory virus complicated by the dirty, smoke-filled air of Kabul. It causes a more prolonged cough along with an increase in sinus infections, asthma flare-ups and even occasional cases of pneumonia. More people arrive in Kabul daily, but not all arrive healthy. More of the one-year contract workers for the Department of State, USAID and the Department of Agriculture are recently retired folks in their 60s to early 70s. They have much-needed skills, but also have the ills many in that age group share – obesity, arthritis, high blood pressure, current or former heart disease, high blood pressure, and even some with diabetes. We work with them the best we can to cover their health care needs. This is not so difficult in Kabul where I have good assistants, a small lab in the health unit, a reference lab in the city, and basic x-rays available at an army base located in Kabul. Managing chronic health conditions in the Provincial Reconstruction Teams (PRTs) is much more difficult because there is no ready access to a lab, x-ray, or hospital. Some PRTs are staffed with physicians in a small MASH-like stabilization tent or Quonset hut. If an emergency arises, people from the PRTs must be helicopter-evacuated to one of 6 regional field hospitals run by various NATO countries. If there is a concurrent emergency need by soldiers for the same helicopters, the military personnel come first. Specific arrangements (Memoranda of Agreement, or MOA) must be executed with each hospital host country to allow USG civilian employees access to medical services.
When someone is seriously ill, I need to use the resources of the French-run military stabilization/evacuation hospital in Kabul. That was especially interesting when I had a man in his 50’s with chest pain and poor heart rhythms that needed to be stabilized and then evacuated to Germany for an angiogram. I was at the hospital, working along with French, Portuguese and German physicians to get him stabilized and ready for transport. It was fascinating to serve together with these talented physicians from other countries. It was even better that we all agreed on exactly what medications, tests, and treatments were needed. Fortunately, that patient did very well as he was eventually treated with a balloon angioplasty and stent to his main heart artery.
We must always be prepared for a medical crisis from fighting in the city. Although Kabul has been relatively safe and stable for many months, there have been several attacks and car bombings by Taliban fighters in recent weeks. I was recently speaking at a medical orientation for new arrivals, when nearby bombs exploded, one after another for an hour or so. That attack, put down successfully by the Afghan army and police, occurred about 1 mile from the embassy. It has caused us to redouble all the security arrangements. We do not travel outside of the embassy compound unless necessary for business or emergencies. So far, no embassy civilians have been hurt or killed in Kabul. But the coming months will remain dangerous. We continue with training and mass casualty drills to be ready for possible injuries in the future.
I recently had the chance to venture outside of Kabul to visit two of the four Regional Command Platforms that serve as headquarters for the USG civilians from many agencies that serve throughout the country in the local provinces. In mid-2008 there were fewer than 50 civilians working in the outlying areas; now there are over 300, with another 300 planned over the coming year. They serve at 64 different outposts. I visited Mazar-i-Sharif in the north and Kandahar in the south. In each command location a small group of civilians live and work among the thousands of army troops. They coordinate the activities of all the people working in the small PRTs and District Support Teams (DSTs). Living accommodations are austere, with barrack accommodations, shared bath facilities, mess hall eating and little opportunity for private space or private time. At the most remote posts, the DSTs, 1-3 American civilians are imbedded with 150-200 soldiers. They live in tents, use latrines, and clean up daily with what amounts to an oversized “Baby Wipe”. Nonetheless, the people I met were hard-working, optimistic and committed to making life better for the Afghan people and helping them develop local and regional government structures that serve the needs of the local population. That is their primary mission, as the military forces oust the Taliban, provide basic security for local villages and cities, and assist in fostering a sense of trust in the local people.
My travel to a small Canadian-run PRT was exciting. I hitched a ride with Canadian troops on a night-time military convoy in armored troop carriers equipped with night-vision cameras. We frequently had to stop while soldiers patrolled the ditches and nearby mud huts for any threats or signs of mines or IEDs along the road. Of course we all wore armored vests and helmets, huddled on our bench seats in a cramped posture for the 1 ½ hour journey. The night I traveled was lucky – the only moving things noted on the scanner were stray dogs and several camels in the yards of their owners! Not all convoys go so well. I now have a first-hand appreciation of the cautious apprehension that is a part of every convoy in a war zone.
The most heart-warming event in my stay in Afghanistan so far occurred while visiting the PRT on the northern outskirts of Kandahar city, where fighting has been fierce in the past two years. A local family brought their 2 year-old daughter to the tiny military health unit after she was scalded by spilled boiling tea down her entire torso. She had extensive burns, not adequately treated by a local physician. I was able to teach a young Canadian physician (just completed her training in the past year) to debride the burn wounds carefully, followed by special antibiotic application and dressings. It will likely take treatments 2-3 times a week for another month, but I think the beautiful girl, named Assima, will eventually heal the wounds. Her father was very appreciative. It is the type of diplomacy that works wonders in building trusting relationships.
Life is full of contrasts. 6 days after returning from the Kandahar province, I packed my bag to head off to Bangkok, Thailand for the annual medical conference sponsored by the Office of Medical Services….
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